Healthcare Provider Details

I. General information

NPI: 1619664117
Provider Name (Legal Business Name): GER M THAO ACSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2023
Last Update Date: 05/01/2023
Certification Date: 05/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 QUEBEC AVE
CORCORAN CA
93212-9715
US

IV. Provider business mailing address

3403 N EZIE AVE
FRESNO CA
93727-8006
US

V. Phone/Fax

Practice location:
  • Phone: 661-992-7100
  • Fax:
Mailing address:
  • Phone: 559-348-7908
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: